Every finding on record at Hospice of the Calumet Area Inc

Based on record review and interview, the hospice failed to evidence a process for cooperation and collaboration with local, state and federal emergency preparedness officials that included documented attempts to contact officials in an effort for collaboration and cooperative planning in 1 of 1 agency.  Findings include: --- A review of the hospice’s Emergency Preparedness Plan on 06/02/2025, failed to evidence documentation of collaboration with local, state and federal emergency preparedness officials. During an interview, on 06/02/2025, beginning at 9:50 AM, the Quality Improvement Coordinator, Administrative Staff 3, indicated the hospice did not have documentation of attempts to collaborate with local, state and federal emergency preparedness officials.

Based on record review and interview, the hospice failed to ensure the patient’s drug profile was reviewed in 1 of 1 clinical record reviewed who resided in an assisted living facility and a home visit observation was conducted (Patient #1) and 1 of 1 clinical record review who resided in a SNF and a home visit was conducted (Patient #2).  Findings include: --- 1. A revised policy dated 12/16/2015 titled, “Assessment Updates to the Comprehensive Assessment,” indicated the comprehensive assessment of the patient included but not limited to a review of all the patient’s prescription and over the counter drugs that could affect drug therapy.  2.   A revised policy, dated 11/10/2020, titled, “Medication Management,” indicated a medication profile would be maintained for every patient.   3.  A revised policy, dated 04/21/2020, titled, “Medication Administration,” indicated at the time of the initial and comprehensive assessment the registered nurse [RN] would verify medications with the patient/caregiver/representative to include over the counter medications, and prescription medications.  4.  A RN Hospice Initial Assessment, dated 03/31/2025, for Patient #1, indicated a medication profile review was completed of prescription /non-prescription medications for new or changed medications and for issues including effectiveness of therapy, side effects, actual/potential interactions and duplicate drug therapy.  Entity E, an assisted living facility, documents indicated Patient moved into the facility on 03/25/2025. Documentation indicated Patient was taking medications to include but not limited to dexamethasone (corticosteroid used to reduce inflammation) 4 milligrams [mg] one tablet twice a day for inflammation. The Report indicated dexamethasone had a start date of 03/29/2025 and was last administered on 05/30/2025.  A Hospice Medication Profile, print date of 05/29/2025, failed to evidence the dexamethasone.  A Plan of Care for the benefit period 03/31/2025 to 06/28/2025, indicated hospice began on 03/31/2025; the POC failed to evidence the dexamethasone.  During an interview, on 06/02/2025, beginning at 1:30 PM, RN 1 indicated the admitting RN should have completed a medication review upon Patient admission and the RN should review medications with the facility staff.  RN 1 indicated she would need to follow up with the facility staff about the use of Patient’s dexamethasone and she was unaware Patient was taking dexamethasone.  5.  A Skilled Nursing Visit Note, identified as a comprehensive assessment, dated 05/22/2025, indicated a medication profile review was completed for Patient #2's prescription/non-prescription medications for new or changed medications and for issues including effectiveness of therapy, side effects, actual/potential interactions, and duplicate drug therapy.  An Entity A, a skilled nursing facility, Physician Order Report, dated 05/02/2025 to 06/02/2025, indicated Patient medications to include but not limited to Tylenol, generic name acetaminophen (pain reliever) extended release 650 mg every 8 hours as needed for pain and Hydrocodone/acetaminophen (narcotic pain reliever) 7.5/325 mg one tablet twice a day.  The Report indicated not to exceed 4 grams of acetaminophen in 24 hours.  A Hospice Plan of Care, for benefit period 04/14/2025 to 06/12/2025, indicated hydrocodone/acetaminophen 7.5/325 mg one tablet twice a day and failed to evidence Tylenol.  A Hospice Medication Profile, printed on 05/29/2025, failed to evidence the Tylenol.  During an interview on 06/03/2025, beginning at 2:00 PM, RN 2 indicated Patient was not using the Tylenol and was taking scheduled Hydrocodone/Acetaminophen.   During an interview, on 06/02/2025, beginning at 1:30 PM, RN 1 indicated the admitting RN should have completed a medication review upon Patient admission and the RN should review medications with the facility staff.

Based on record review and interview, the hospice failed to ensure the interdisciplinary group maintained responsibility for directing, coordinating and supervising the care and services provided in 1 of 1 active clinical record reviewed of a patient who resided in a skilled nursing facility and a home visit observation was completed (Patient #2). Findings include: --- A revised policy, dated 04/21/2020, titled, “Coordination of Services,” indicated the registered nurse [RN] case manager would coordinate the patient’s plan of care and facilitate the ongoing sharing of information with the contracted facility and non-hospice healthcare providers furnishing services unrelated to the terminal illness. A Patient Care Order, dated 05/19/2025, indicated Patient #2's right forearm skin tear orders included clean with normal saline, and apply foam dressing 2 days per week and as needed and indicated the wound care orders were provided by the wound care team Person C, from Entity A, a skilled nursing facility. An entity A, wound care order, dated 05/16/2025, indicated cleanse right elbow skin tear with normal saline, pat dry, apply polymem (wound covering), then cover with foam dressing every Tuesday, Friday and as needed.   An entity A, wound care order, dated 05/22/2025, indicated cleanse right elbow skin tear with normal saline, pat dry, apply polymem, then cover with foam dressing every Tuesday, Friday and as needed. Hospice Skilled Nursing Visit Notes, dated 05/22/2025 and 05/27/2025, indicated the right upper arm forearm skin tear was cleansed with normal saline and covered with a foam dressing. The hospice order failed to evidence the skilled nursing facility wound care team’s order for polymem wound covering to be applied prior to the foam dressing. During an interview, on 06/03/2025, beginning at 2:00 PM, RN 2 indicated she should have obtained the skilled nursing facility’s wound care updated orders for Patient’s right arm skin tear and did not.  RN 2 indicated the skilled nursing facility’s wound care team would often do wound care prior to hospice nurse visits.  During an interview, on 06/05/ 2025, beginning at 10:00 AM, Person C, from Entity 1 indicated Patient’s wound care orders for the right arm skin tear always included the use of a polymem wound covering prior to the foam dressing due to polymem would prevent the foam dressing from sticking to the skin tear.

Based on record review and interview, the hospice failed to ensure care and services are provided in accordance with the plan of care in 1 of 1 active clinical records reviewed with a gastrostomy tube (Patient #8).  Findings include: --- A revised policy, dated 08/31/2021 and titled “Plan of Care,” indicated the plan of care would be developed by the interdisciplinary group [IDG] in accordance with the physician orders and comprehensive assessment of the patient to identify the care and services necessary to meet the needs of the patient/caregiver.  The policy indicated the patient’s plan of care would include but not limited to treatments necessary to meet the needs of the patient.  A POC for the benefit period 04/04/2025 to 06/02/2025, indicated Patient #8's gastrostomy (surgical opening into the stomach from the abdomen for nutrition) site and function would be monitored and the area around the site would be cleansed daily.  A Skilled Nursing Visit Note, dated 05/29/2025, identified as a comprehensive assessment, indicated Patient had a g-tube (gastrostomy tube); the comprehensive assessment failed to include documentation of the assessment of the site or function of the g-tube.  During an interview, on 06/04/2025, beginning at 4:30 PM, the Family Clinical Coordinator, Administrative Staff 2, indicated the comprehensive assessment from 05/29/2025 did not have assessment of the g-tube site and the nurse should have documented the assessment of the site.

Based on record review and interview, the hospice failed to evidence they provided for ongoing sharing of information with non-hospice healthcare providers furnishing services in 3 of 3 active clinical records reviewed of patients residing in a skilled nursing facility with advanced directives (Patient #2, Patient #10, and Patient #12).  Findings include: --- 1.  A revised policy, dated 12/15/2018, titled “Nursing Facility Residents Coordination of Care,” indicated the following information was to be provided to the facility to include but not limited to advanced directives specific to each patient. 2. A revised policy, dated 08/31/2021, titled “Nursing Facility Residents Hospice Plan of Care,” indicated the registered nurse [RN] case manager assigned to the patient was responsible for coordinating and implementing the patient’s plan of care in collaboration with the hospice’s interdisciplinary team and with representatives from the facility.  The policy indicated all care provided to the facility patient would be in accordance with the written plan of care that included the patient’s medical, physical, social, emotional and spiritual needs. 3. A revised policy, dated 02/20/2025, titled “Advanced Directives,” indicated valid advanced directives would be followed to the extent that they are consistent with the hospice’s policies, and in the event a patient chose a life prolonging advanced directive, the hospice would assist the patient and family in locating an appropriate health care provider.  The policy indicated the advanced directives recognized would include but not limited to out of hospital do not resuscitate declaration and allowed a patient to say they did not want cardiopulmonary resuscitation [CPR] if the heart or lungs stopped working in a location that was not a hospital or health facility, and a physician orders for scope of treatment [POST] was a direct physician order that reflected a patient’s wishes related to CPR, medical interventions, antibiotics, and artificially administered nutrition. 4.  A revised policy, dated 04/21/2020, titled “Coordination of Services,” indicated the interdisciplinary group [IDG] would ensure that there was coordinated and effective sharing of information between all disciplines, with all contracted service providers and in all settings.  The policy indicated the RN case manager would coordinate the patient’s plan of care and facilitate the ongoing sharing of information with the attending physician, contracted facilities, other members of the IDG, and non-hospice healthcare providers furnishing services unrelated to the terminal illness.  5. A Hospice Plan of Care for the benefit period 04/14/2025 to 06/12/2025, indicated Patient #2's hospice care began on 04/19/2024 and that Patient was a Full Code (CPR would be used if a patient’s heart or breathing stopped).  The POC indicated under Patient had a healthcare proxy and resided in Entity A, a skilled nursing facility [SNF]. A Physician Order Report from Entity A and dated 05/02/2025 to 06/02/2025, indicated Patient was a DNR.  During an interview, on 06/02/2025 beginning at 10:30 AM, RN 2 indicated Patient was not a DNR and the facility would do CPR on Patient if required, indicated hospice patients were able to receive CPR.During an interview, on 06/02/2025 beginning at 10:30 AM, Licensed Practical Nurse D, of Entity A indicated Patient was a DNR and presented documentation of a Physician Orders for Scope of Treatment [POST] for Patient.  The POST Document, received from Entity A on 06/02/2025, indicated Patient was a DNR and was signed on 03/29/2022. During an interview, on 06/02/2025 beginning at 1:00 PM, masters of social worker [MSW] 1 indicated she would need to follow up with the Social Worker [SW] responsible to have advanced directives documents in Patient’s clinical record.During a follow up interview, on 06/02/2025 beginning at 1:45 PM, MSW 1 indicated the SW did not follow up on the advanced directive document or with the SNF.  MSW 1 indicated the SW was to enter Patient’s DNR status on the POC after documentation was received or completed. 6. The POC for the initial benefit period 05/23/2025 to 08/20/2025, indicated Patient #10 was not a DNR and indicated no advanced directives.  The POC indicated Patient resided in Entity A. A MSW visit note, dated 05/28/2025, indicated Patient had advanced directives to include a DNR, living will, and health care proxy. During a follow up interview, on 06/02/2025, beginning at 1:45 PM, MSW 1 indicated the hospice SW was to enter Patient’s DNR status on the POC after documentation was received; the MSW relayed the SW was responsible for obtaining advanced directive documentation and adding the code status and or DNR to the POC.During an interview, on 06/03/2025 beginning at 4:20 PM, MSW 1 indicated she does not know the status of Patient’s DNR, and the hospice does not have the DNR document.  7. The POC for the 2nd benefit period dated 05/26/2025 to 08/23/2025 indicated Patient #12 was not a DNR and indicated Patient had a surrogate decision maker and a healthcare proxy. A MSW visit note, dated 02/26/2025, indicated Patient's advanced directives included documents of DNR, living will, and healthcare proxy.A POST dated 04/29/2025, was received on 06/03/2025, from Entity B, a SNF; the POST indicated Patient was a DNR. During an interview, on 06/03/2025, beginning at 4:00 PM, MSW 1 indicated she received the DNR document from Entity B via fax on 06/03/2025, and the SW was responsible for documenting Patient’s advanced directives on the POC and did not.  MSW 1 indicated hospice did not have Patient’s DNR document in the electronic clinical record.8. During an interview, on 06/02/2025 beginning at 1:00 PM, the Administrator indicated their patients POC should have included their advanced directives.

Based on record review and interview, the hospice failed to evidence the performance improvement activities focused on high risk, high volume or problem prone area in 12% of the 12 month unduplicated census of patients with documented falls from 05/02/2024 to 05/18/2025. Findings include: --- A revised policy, dated 08/15/2017 and titled, “QAPI [quality assurance performance improvement] Program Data,” indicated priorities for data collection and measurement activities are based on the identification of negative trends and areas that require a more focused review and analysis. A revised policy, dated 12/02/2008 and titled, “QAPI Performance Improvement Activities and Projects,” indicated performance improvement activities are selected that are focused on high risk, high volume or problem prone areas and would consider incidence, prevalence of severity of problems in high risk, high volume or problem prone areas and affect palliative outcomes, patient safety and quality of care. A Quality Assurance Performance Improvement Plan, dated 2025, indicated the performance improvement team would consider the following factors when prioritizing problem and solution selections for performance improvement projects to include but not limited to high risk, high volume, problem prone areas, and the frequency of the problem and severity of potential harm.A Hospice Fall Log for 2024 indicated 57 patients had falls.  Hospice Fall Log for 2025 indicated 22 patients had falls from 01/04/2025 to 05/18/2025.  A Quality Assurance Performance Plan failed to evidence the hospice performance improvement activities focused on patients’ falls and failed to evidence analysis of patients' to an action plan. During an interview, on 06/03/2025, beginning at 10:30 AM, the Performance Improvement Coordinator, Administrative Staff 3, indicated the QAPI program did not analyze or have an action plan in place for patients’ falls.

Based on record review and interview, the hospice failed to track adverse events for performance improvement activities in 1 of 2 active clinical records reviewed with a documented fall (Patient #12).  Findings include: --- A Quality Assurance Performance Improvement Plan, dated 2025, indicated the objectives of the plan would be to measure, analyze and track quality indicators, including adverse events, to enable the assessment of processes of care and hospice services. A Skilled Nursing Visit Note, dated 05/06/2025, indicated the hospice social worker contacted the nurse to report that Patient #12’s family member had reported Patient was found on the floor, beside the bed and Patient was unable to tell the staff what had happened. A Hospice Fall Log, dated 2025, failed to evidence documentation of Patient’s fall.During an interview on 06/03/2025, beginning at 1:00 PM, the Performance Improvement Coordinator, Administrative Staff 3 indicated an adverse event for Patient’s fall was not on the fall log and an adverse event report should have been completed by the nurse and was not.

Based on record review and interview, the Quality Assessment and Performance Improvement [QAPI] Program failed to evidence a method of identifying urinary tract infections and implementing an action plan that would result in improvement and disease prevention in 12% of the 12 month unduplicated census of urinary tract infections from Quarter 3 to Quarter 4 in 2024, and January 2025 to May 2025.   Findings include: --- A revised policy, dated 08/15/2017 and titled, “QAPI Program Data,” indicated the performance improvement team would be responsible for reviewing and analyzing routine data that would be collected by the hospice program that would include but not limited to infection surveillance data.  The policy indicated the performance  improvement team would utilize the results of the data analyzed to monitor the effectiveness and safety of services and the quality of care to identify performance improvement opportunities.A revised policy, dated 12/02/2008 and titled, “QAPI Performance Improvement Activities and Projects,” indicated the performance improvement team would make recommendations for potential performance improvement activities and projects that reflects areas of weakness as identified through data analysis.  The policy indicated the performance improvement activities would be selected that included focus on high risk, high volume or problem prone areas, consider incidence, prevalence and severity of problems in highs risk areas and activities that would affect palliative outcomes, patient safety and quality of care. A 2024 Summary of Logs for Patients’ Urinary Tract Infections [UTI] indicated 12 UTI for Quarter 1 of 2024, 15 for Quarter 2 of 2024, 13 for Quarter 3 of 2024 and 14 for Quarter 4 of 2024. A  2025 Infection Log indicated 32 patients with urinary tract infections from 01/07/2025 to 05/18/2025. During an interview, on 06/03/2025, beginning at 10:30 AM, the Performance Improvement Coordinator, Administrative Staff 3, indicated the hospice’s QAPI program did not include an action plan related to patients’ urinary tract infections.

Based on record review and interview, the hospice failed to evidence they collected and maintained documentation of advanced directives in 2 of 2 clinical records reviewed where the patients resided in a skilled nursing facility and whose hospice care began before 05/23/2025 (Patient #2 and Patient #12). Findings include: --- 1.       A revised policy, dated 02/20/2025, titled, “Advance Directives,” indicated at the time of admission to the hospice program the existence of an advance directive would be documented, and a copy would be requested for the patient’s medical record. 2.       A Hospice POC for the benefit period 04/14/2025 to 06/12/2025, indicated Patient #2 who began hospice services on 04/19/2024, was not a do not resuscitate [DNR] (CPR would not be used if a patient’s heart or breathing stopped).  The POC indicated Patient had a healthcare proxy.A Physician Order Report dated 05/02/2025 to 06/02/2025, from Entity A a SNF, indicated Patient was a DNR and provided a Physician Orders for Scope of Treatment [POST] Document, on 06/02/2025 which indicated Patient was a DNR; the document was signed on 03/29/2022.During an interview, on 06/02/2025 beginning at 1:45 PM, MSW 1 indicated the SW did not follow up on the advanced directive document or with the SNF. MSW 1 indicated the SW was to enter Patient’s DNR status once received or completed and to add to the clinical record. 3.       Plan of Care, for the 2nd benefit period 05/26/2025 to 08/23/2025, indicated Patient #12 was not a DNR and indicated Patient had a surrogate decision maker and healthcare proxy.  The record included a MSW Visit Note, dated 02/26/2025, which indicated Patient's advanced directives included documentation of a DNR, living will and healthcare proxy. The clinical record failed to evidence documents to evidence Patients' code status to be a fill code, a DNR, or other choice.4.       During an interview, on 06/03/2025, beginning at 4:00 PM, MSW 1 indicated she received the DNR document from entity B via fax on 06/03/2025. MSW 1 indicated that the hospice did not have Patient’s DNR document in the electronic clinical record.

Based on record review, and interview, the hospice failed to ensure patients’ plans of care identified the care and services that were needed and identify which provider was responsible for performing those functions for 3 of 3 active clinical records reviewed of patients residing in a skilled nursing facility (Patient #2, Patient #10, Patient #12).  Findings include: --- 1.   A revised policy, dated 08/31/2021, titled, “Nursing Facility Residents Hospice Plan of Care,” indicated the plan of care for the facility patient would identify the care and services that were needed and specifically identify which provider was responsible for performing the functions. 2. A Plan of Care, for benefit period 04/14/2025 to 06/12/2025, indicated Patient #2 was disoriented, incontinent of bowel and bladder, required 24 hour supervision, was on complete bedrest, had wound care to the left knee daily, and left calf wound care 2 times per week.A Skilled Nursing Visit Note, dated 05/22/2025, indicated Patient had a Karnofsky Performance Status Score (an assessment tool for functional impairment) of 30% that indicated Patient was unable to care for self and was severely disabled. A Hospice/Nursing Facility Coordinated Services Plan of Care from Entity A, a SNF, indicated hospice nurse visits were Monday and Thursday, 04/14/2025 to 06/12/2025, and hospice aide visits were Monday, Wednesday and Friday.  The Hospice /Nursing Facility coordinated Services Plan of Care indicated a wound care schedule for hospice wound care, beginning of 04/14/2025, was Monday, Wednesday, and Friday for knee wound care 2 times per week and daily calf wound care.  The POC failed to evidence the care to be provided, the wound care to be provided and the activities of daily living to be provided by the skilled nursing facility in the absence of the hospice staff.  3.  A POC for the benefit period 05/23/2025 to 08/20/2025, indicated Patient #10 required wound care to left foot, right foot, and right thigh 2 times per week and as needed if the dressing became loose, soiled, or dislodged and was short of breath with minimal exertion. An Aide Care Plan, dated 06/03/2025, indicated Patient’s activity was to be up to wheelchair with maximum assistance with facility staff assistance, and incontinent care, and bed bath were to be completed by the hospice aide.  A Hospice /Nursing Facility Coordinated Services Plan of Care indicated hospice nurse visits and hospice wound care was Mondays and Thursdays and hospice aide visits were Monday, Wednesday and Friday.  The POC failed to evidence the care to be provided by the skilled nursing facility in the absence of the hospice staff. 4. A POC for the benefit period 05/26/2025 to 08/23/2025, indicated Patient #12 was incontinent of bowel and bladder, was lethargic, required 24 hour supervision, had a foley catheter (a tube that drains urine), diet was pleasure feeds as tolerated,  and required wound care to a buttocks wound 3 times per week on Monday, Wednesday, Friday and as needed for soilage.  The record included an Order, dated 05/31/2025, which indicated buttocks deep tissue injury wound care daily.  A Hospice / Nursing Facility Coordinated Services Plan of Care, indicated hospice nurse visits and wound care on Tuesday and Friday, hospice aide visits Tuesday, Thursday and Friday, and foley catheter change.  The Coordinated Services Plan of Care indicated foley catheter change 04/23/2025 and under party responsible and frequency hospice or long term care the area was blank.   The POC failed to evidence the care to be provided by the skilled nursing facility in the absence of the hospice staff.  During an interview, on 06/02/2025, beginning at 1:00 PM, the Patient Care Coordinator, indicated the hospice was responsible for the management of their patients and the delineation of care did not include the skilled nursing facility’s responsibilities.

Based on record review and interview, the agency failed to develop and implement emergency preparedness policies and procedures based on their risk assessment The findings include: An agency document titled "Emergency Management Procedures-Field Patients" revised 7/11/2019, stated "To establish guidelines for Hospice of the Calumet Area (HCA) partners and volunteers to follow when caring for field patients and their caregivers in the event of an emergency or disaster ... Emergency Procedures Related Specific High-Risk Events Tornados ... Winter Storms ... Flooding ... Power Outage ... This Plan was developed based on the completion of a facility-based risk Assessment that utilized an all-hazard approach. The risk assessment identified types of hazards that the organization is most susceptible to ...." An agency document titled "Emergency Preparedness Community Risk Assessment" dated 2022-2023 received on 6/20/2022, evidenced Ice/Snow/Blizzards, Flooding, earthquake, and tornado as the facility's high-risk hazards. Record review of the agency's risk assessment and policies and procedures failed to evidence a plan for earthquakes in their policies and procedures. During an interview on 6/20/2022 at 2:00 PM, the Performance Improvement officer/corporate compliance officer indicated she did not see the earthquakes listed in the plan.

5. Clinical record review for patient #9 on 6/22/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Encephalopathy (any brain disease that alters brain function or structure), evidenced an agency document titled, "Skilled Nursing Visit Note", dated 6/14/2022, and signed by RN H, which stated, " ... Assessment Type Hospice Comprehensive Assessment ... REVIEW OF SYSTEMS - REPRODUCTIVE Clinical Findings: ... Female Assessment ... Gynecologic Findings Post Menopausal ...." Clinical record review evidenced an agency document titled, "Hospice Plan of Care". The plan of care had a section titled, "Sex", which indicated the patient was male. Clinical record review of all other assessments indicated the patient was male. During an interview on 6/23/2022 at 1:30 PM, RN B indicated patient #9 was male. When informed of the findings, RN B indicated the reproductive assessment documented by RN H in the comprehensive assessment was incorrect. Based on record review and interview, the agency failed to ensure the comprehensive assessment was accurate and included the assessment of wounds in 3 of 6 clinical records reviewed with wounds. (#4, 5, 9) The findings include: 1. Review of an agency policy obtained 6/22/2022, titled "Assessment - Comprehensive Assessment of the Patient" revised 4/21/2020, stated, "... The comprehensive assessment of the patient consists of discipline-specific assessment tools that address the following factors: ... Hospice of the Calumet Area (HCA) interdisciplinary group conducts and documents a patient-specific comprehensive assessment that identifies the patient's need for hospice care, including physical, medical, nursing, psychosocial, emotional and spiritual care...." 2. Review of an undated agency document obtained 6/22/2022, titled "Skin Care Protocol" stated, "... For any areas of skin breakdown, note location, stage (if a pressure ulcer) [wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage I (a pressure wound that is not open], size (length, width, depth), tissue type ... tenderness/pain, drainage, odor and condition of surrounding skin...." 3. Clinical record review on 6/16/2022, for patient #4, start of care 6/11/2022, evidenced an agency document titled "Skilled Nursing Visit Note" completed by the registered nurse (RN) and dated 6/11/2022, which indicated the visit was the initial assessment. Review indicated the patient had multiple venous stasis ulcers (wounds caused by damaged veins) to both legs which the patient would scratch causing the patient to bleed. Review failed to evidence the RN assessed the open areas per the agency's policy to include in the comprehensive assessment the measurements and descriptions of the wounds. During an interview on 6/22/2022, at 9:59 AM, RN C indicated she did not see an assessment of the wounds in the initial assessment. 4. Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, evidenced an agency document titled "Skilled Nursing Visit Note" completed by the RN and dated 3/24/2022, which indicated the visit was the initial assessment. Review indicated the patient had a pressure ulcer to the sacrum (the area on the back at the bottom of the spine and above the buttocks) and a deep tissue injury to the left hip. Review failed to evidence the registered nurse followed the agency's policy to include in the comprehensive assessment the measurements and descriptions of the wounds. During an interview on 6/22/2022, at 9:53 AM, registered nurse C indicated the wound assessment should include the size, location, and description of each wound. At 11:10 AM, RN C indicated the initial comprehensive assessment did not include a complete wound assessment of the sacrum and left hip. At 2:41 PM, RN C indicated there was not an assessment in the clinical record of the deep tissue injury to the left hip from the start of care date to current.

Based on observation, record review, and interview, the agency failed to ensure the services provided to the patients followed the plan of care in 1 of 4 active clinical records reviewed with wounds. (#4) The findings include: Review of an agency policy obtained 6/22/2022, titled "Plan of Care" revised 8/31/2021, stated, "... Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care ...." Review of an undated agency document obtained 6/22/2022, titled "Skin Care Protocol" stated, "... For any areas of skin breakdown, note location, stage (if a pressure ulcer) [wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage I (a pressure wound that is not open], size (length, width, depth), tissue type ... tenderness/pain, drainage, odor and condition of surrounding skin...." Clinical record review on 6/16/2022, for patient #4, start of care 6/11/2022, evidenced an agency document titled "Hospice Plan of Care" for certification period 6/11/2022 - 9/8/2022. Review indicated the nurse was to assess wound status including signs and symptoms of healing and complications. During an observation of care at the patient's home on 6/17/2022, at 10:30 AM, the patient was observed with multiple open areas to both legs. Registered Nurse (RN) D was observed cleaning the wounds and applying an ointment and band aids to 7 wounds on the front and back of the left leg. Review evidenced agency document titled "Skilled Nursing Visit Note" completed by the registered nurse (RN) and dated 6/17/2022. Review indicated RN D assessed the wounds to 5 wounds to the left leg. Review failed to evidence an assessment for all 7 wounds the RN provided wound care to on the left leg. During an interview on 6/22/2022, at 10:37 AM, RN C indicated all wounds should be assessed and documented in the visit notes.

10. Clinical record review on 6/16/2022, for patient #4, start of care 6/11/2022, evidenced an agency document titled "Skilled Nursing Visit Note" completed by the registered nurse (RN) and dated 6/11/2022. Review indicated the visit was the initial assessment and indicated the patient required supplemental oxygen at 2 liters per minute and smoked everyday. Review indicated the patient had multiple venous stasis ulcers (wounds caused by damaged veins) to both legs which the patient would scratch causing the patient to bleed. Review of an agency document titled "Hospice Plan of Care" for certification period 6/11/2022 - 9/8/2022, evidenced the patient was to use oxygen 2-4 lpm and the nurse may titrate to 6 lpm. Review failed to evidence the plan of care was individualized to include patient-specific direction for the amount of oxygen to be administered and patient-specific direction for the titration of the oxygen. Review indicated the patient may have a foley catheter (a plastic tube inserted into the bladder to drain urine) inserted as needed. Review failed to evidence the plan of care included the size of the catheter to be inserted. Review indicated the foley catheter could be irrigated as needed and failed to evidence with what and how much was to be irrigate and for what indications the foley catheter was to be irrigated. Review failed to evidence the plan of care was individualized to include patient/caregiver education related to the safety of oxygen use. Review indicated the nurse was to perform wound care as per current physician orders. Review failed to evidence an order for wound care before 6/13/2022. During an interview on 6/22/2022, at 10:05 AM, RN C indicated the plan of care should include patient/caregiver education to not smoke while wearing oxygen and maintain distance from oxygen source while smoking. During an interview on 6/22/2022, at 2:03 PM, the patient family care coordinator indicated there was not a wound care order before 6/13/2022. The patient family care coordinator indicated the admission nurse should have included the wound orders on the plan of care at time of admission. 11. Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, evidenced an agency document titled "Hospice Plan of Care" for certification period 3/24/2022 - 6/21/2022, which indicated the patient may have a foley catheter inserted as needed. Review failed to evidence the plan of care included the size of the catheter to be inserted. Review indicated the foley catheter could be irrigated as needed and failed to evidence with what and how much was to be irrigated and for what indications the foley catheter was to be irrigated. Review evidenced an agency document titled "Skilled Nursing Visit Note" dated 3/24/2022, which indicated the patient had a condom catheter (a plastic tube connected to a collection device that fits over the penis like a condom that drains urine from the body). Review of the plan of care failed to evidence orders for the condom catheter to include how often the condom catheter was to be changed. Review indicated the patient had a pressure ulcer (wounds to the skin and underlying tissue resulting from prolonged pressure to the skin) stage I (a pressure wound that is not open) to the sacrum (the area on the back at the bottom of the spine and above the buttocks) and a deep tissue injury to the left hip. The plan of care failed to evidence an order for wound care to the pressure ulcer to the sacrum prior to 3/29/2022 and failed to evidence a wound order for the deep tissue injury to the left hip. During an interview on 6/22/2022, at 11:03 AM, RN C indicated the plan of care should include orders for the condom catheter. At 11:08 AM, RN C indicated the plan of care should have included a wound order for the pressure ulcer to the sacrum before 3/29/2022 and should include a wound order for the deep tissue injury to the left hip. Review of an agency document titled "Patient Changes Document" for the period 3/29/2022 - 4/12/2022, indicated the patient was to be suctioned as needed. Review failed to evidence the plan of care included with what the patient was to be suctioned, at what pressure, how often, and for what indications. During an interview on 6/22/2022, at 11:18 AM, RN C indicated the plan of care should explain the patient should be suctioned for difficulty breathing and gurgling. RN C indicated she believed the order was a standard order and not a patient-specific order. 12. Clinical record review on 6/17/2022, for patient #6, start of care 6/30/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 4/26/2022-6/24/2022. Review evidenced the patient may have a foley catheter inserted as needed. Review failed to evidence the plan of care included the size of the catheter to be inserted. Review indicated the foley catheter could be irrigated as needed and failed to evidence with what and how much was to be irrigate and for what indications the foley catheter was to be irrigated. 13. Clinical record review on 6/21/2022, for patient #12, start of care 6/21/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 6/21/2021-9/18/2021. Review evidenced the patient may have a foley catheter inserted as needed. Review failed to evidence the plan of care included the size of the catheter to be inserted. Review indicated the foley catheter could be irrigated as needed and failed to evidence with what and how much was to be irrigate and for what indications the foley catheter was to be irrigated. Review evidenced the patient was to use oxygen 2-4 lpm and the nurse may titrate to 6 lpm. Review failed to evidence the plan of care was individualized to include patient-specific direction for the amount of oxygen to be administered and patient-specific direction for the titration of the oxygen. 14. Clinical record review on 6/21/2022, for patient #13, start of care 7/26/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 7/26/2021-10/23/2021. Review evidenced the patient may have a foley catheter inserted as needed. Review failed to evidence the plan of care included the size of the catheter to be inserted. Review indicated the foley catheter could be irrigated as needed and failed to evidence with what and how much was to be irrigate and for what indications the foley catheter was to be irrigated. Review evidenced the patient was to use oxygen 2-4 lpm and the nurse may titrate to 6 lpm. Review failed to evidence the plan of care was individualized to include patient-specific direction for the amount of oxygen to be administered and patient-specific direction for the titration of the oxygen. 15. During an interview on 6/22/2022, at 10:14 AM, RN C indicated the plans of care did not include a size for the foley catheter. RN C indicated the plans of care included standard orders for the foley catheter and irrigation of the foley catheter and indicated the plans of care should be a follow-up order with specific patient orders for the size of the foley catheter and what the foley catheter should be irrigated with, how much, and reasons indicating irrigation was needed. 16. During an interview on 6/22/2022, at 10:08 AM, RN C indicated there should be some direction in the plan of care about what amount of oxygen the patient should have when a range is ordered and should have some direction about how and why the nurse should titrate oxygen. 6. Clinical record review for patient #2 on 6/21/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Senile degeneration of brain, evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Orders / Treatments:", which stated, " ... Urinary Catheter: Insert Foley catheter [a tube inserted through the urethra to drain the bladder]or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN ...." Review of the plan of care failed to evidence specific instruction for size and type of catheter to use, how to irrigate the catheter, set frequency for changing the catheter, and what indications were for PRN catheter change. Clinical record review evidenced an agency document titled, "VERBAL ORDER", identified by the administrator as part of the agency's plan of care, dated 6/16/2022, which stated, " ... PRN Wound Care for Stage II: Cleanse wound with normal saline and apply skin barrier and/or absorbent dressing. Change dressing every 3-5 days and PRN if soiled or dislodged ...." Review of the order failed to evidence the location of the wound. Review of the order failed to evidence set frequency for changing the dressing and clear instruction on what wound care products should be used. 7. Clinical record review for patient #8 on 6/22/2022, start of care 3/3/2022, certification period 6/1/2022 to 8/29/2022, primary diagnosis of Alzheimer's disease, evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Orders / Treatments:", which stated, " ... Urinary Catheter: Insert Foley catheter [a tube inserted through the urethra to drain the bladder]or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN ...." Review of the plan of care failed to evidence specific instruction for size and type of catheter to use, how to irrigate the catheter, set frequency for changing the catheter, and what indications were for PRN catheter change. 8. Clinical record review for patient #9 on 6/22/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Encephalopathy (any brain disease that alters brain function or structure), evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Orders / Treatments:", which stated, " ... Urinary Catheter: Insert Foley catheter [a tube inserted through the urethra to drain the bladder]or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN ...." Review of the plan of care failed to evidence specific instruction for size and type of catheter to use, how to irrigate the catheter, set frequency for changing the catheter, and what indications were for PRN catheter change. Clinical record review evidenced an agency document titled, "Skilled Nursing Visit Note", dated 6/14/2022, signed by RN (registered nurse) F, which stated, " ... Assessment Type Hospice Initial Assessment ... REVIEW OF SYSTEMS - REPRODUCTIVE ... [family member B] ... shares ... [patient #9] ... was informed of having breast cancer approx. 8 weeks ago ...." Review of the plan of care failed to evidence the patient had breast cancer. During an interview on 6/23/2022 at 3:53 PM, RN B indicated significant diagnoses should be included in the plan of care. When informed of the findings, RN B indicated RN F should have included the information in the admission prep note so the medical director could review it. RN B reviewed the patient's record and stated, "I don't see anything". 9. Clinical record review for patient #10 on 6/22/2022 for patient #10 on 6/22/2022, start of care 5/11/2021, certification period 5/11/2021 to 8/8/2021, primary diagnosis of Heart failure evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Orders / Treatments:", which stated, " ... Urinary Catheter: Insert Foley catheter [a tube inserted through the urethra to drain the bladder]or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN ...." Review of the plan of care failed to evidence specific instruction for size and type of catheter to use, how to irrigate the catheter, set frequency for changing the catheter, and what indications were for PRN catheter change. Based on record review and interview, the hospice agency failed to ensure all patients' plan of care was individualized to that specific patient and their needs in 13 of 13 clinical records reviewed. (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) The findings include: 1. The agency policy titled "Plan of Care" revised 8/31/2021, stated "... Policy: Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by members of the interdisciplinary group (IDG) in collaboration with the patient's attending physician (if any), the patient or representative and the primary caregiver. ... 2. The plan of care will be developed by the IDG in accordance with the physician's orders and the initial and comprehensive assessment of the patient which identify the care and services necessary to meet the needs of the patient/caregiver. ... 4. The patient's plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care includes, but is not limited to: a. Identification of problems. b. Measurable outcomes anticipated from implementing and coordinating the plan of care. c. A statement of the scope and frequency of services necessary to meet the specific patient and family needs. d. Interventions to manage pain and symptoms. e. Drugs and treatment necessary to meet the needs of the patient. f. Medical supplies and appliances necessary to meet the needs of the patient. g. Documentation of the patient's or representative's level of understanding, involvement and agreement with the plan of care, those impediments are documented in the patient's clinical record and the level of understanding or lack of understanding are recorded...." 2. Clinical record review on 6/23/2022 for patient #3, start of care 11/05/2020, and a primary diagnosis of Alzheimer's Disease (a brain disorder affecting memory and thinking) evidenced an agency document titled "Hospice Plan of Care" for certification period 4/29/2022 - 6/27/2022, dated and electronically signed by employee B on 4/26/2022, and dated and signed by the attending physician on 5/10/2022. This plan of care had an area subtitled "Additional Services" which stated, "Urinary Catheter: Insert Foley catheter or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN...." Review of the plan of care failed to evidence specific instructions for size and type of catheter to use, how to irrigate the catheter, the frequency for changing the catheter, and what indications were for PRN catheter change. 3. Clinical record review on 6/23/2022 for patient #7, start of care 3/31/2022, and a primary diagnosis of Cutaneous T-cell lymphoma (Cancer that beings in the white blood cells) evidenced an agency document titled "Hospice Plan of Care" for certification period 3/31/2022 - 6/28/2022, dated and electronically signed by employee F on 4/4/2022, and dated and signed by the attending physician on 4/5/2022. This plan of care had an area subtitled "Additional Services" which stated, "Urinary Catheter: Insert Foley catheter or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN...." Review of the plan of care failed to evidence specific instructions for size and type of catheter to use, how to irrigate the catheter, the frequency for changing the catheter, and what indications were for PRN catheter change. Clinical record review on 6/23/2022 for patient #7 evidenced an agency document titled "Verbal Order signed by RN G and dated on 4/23/2022, and signed by the attending physician on 4/25/2022. This document stated: oxygen via device: Administer 2-4 liters per minute inhaled via nasal cannula PRN for dyspnea [shortness of breath]. This order failed to be included on the plan of care. 4. Clinical record review on 6/22/2022 for patient #1, start of care 2/9/2022, and a primary diagnosis of Post COVID-19 condition and Adult failure to thrive evidenced an agency document titled "Hospice Plan of Care" for certification period 5/10/2022 - 8/7/2022, dated and electronically signed by RN H on 5/9/2022, and dated and signed by the attending physician on 4/12/2022. This plan of care had an area subtitled "Additional Services" which stated, "Urinary Catheter: Insert Foley catheter or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN ... oxygen liters per minute 2-4 liters per minute via nasal cannula as needed May titrate up to 6 liters...." Review of the plan of care failed to evidence specific instructions for size and type of catheter to use, how to irrigate the catheter, the frequency for changing the catheter, and what indications were for PRN catheter change. 5. Clinical record review on 6/22/2022 for patient #11, start of care 9/30/2021, and a primary diagnosis of Malnutrition (the body does not get enough nutrients) evidenced an agency document titled "Hospice Plan of Care" for certification period 9/30/2021 - 12/28/2021, dated and electronically signed by the RN on 10/1/2021, and the attending physician on 10/2/2021. This plan of care had an area subtitled "Additional Services" which stated, "Urinary Catheter: Insert Foley catheter or external catheter PRN [as needed] for relief of urinary retention or incontinence. Empty foley bag PRN. May irrigate PRN. Change indwelling catheter every 30 days PRN ..."Review of the plan of care failed to evidence specific instructions for size and type of catheter to use, how to irrigate the catheter, the frequency for changing the catheter, and what indications were for PRN catheter change.

4. Clinical record review on 6/23/2022 for patient #3, start of care 11/05/2020, and a primary diagnosis of Alzheimer's Disease (a brain disorder affecting memory and thinking) evidenced an agency document titled "Hospice Plan of Care" for certification period 4/29/2022 - 6/27/2022, dated and electronically signed by employee B on 4/26/2022, and dated and signed by the attending physician on 5/10/2022. This plan of care had an area subtitled "Goals" which stated Aide: Patient's personal care needs will be met ... Pt's [patient's family and SNF [skilled nursing facility] unit nurses/caregivers will verbalize knowledge/understanding if end-stage terminal process; and SNF caregivers will implement hospice-directed strategies for providing safe and effective comfort for Pt as she progresses through end-stages of terminal disease process Family and caregiver maintain and modify environment according to patient's cognitive and comfort status Continuity of care will be maintained as appropriate to patient/caregiver needs Family/caregiver will verbalize understanding of Pt's pain and anxiety/restlessness management regimen Family/caregiver will verbalize understanding of disease process, including prognosis, symptoms, treatment, and complications ... This plan of care failed to evidence measurable goals for the patient and caregivers. 5. Clinical record review on 6/23/2022 for patient #7, start of care 3/31/2022, and a primary diagnosis of Cutaneous T-cell lymphoma (Cancer that beings in the white blood cells) evidenced an agency document titled "Hospice Plan of Care" for certification period 3/31/2022 - 6/28/2022, dated and electronically signed by employee F on 4/4/2022, and dated and signed by the attending physician on 4/5/2022. This plan of care had an area subtitled "Goals" which stated Aide: Patient's personal care needs will be met ... Primary family goal for [patient] to be comfortable ... Caregiver will verbalize understanding of pain and symptom management regimen ... Caregiver will demonstrate necessary behaviors to maintain good safety and symptom management regimen ... Family and caregiver will demonstrate the ability to cope with limitations ...." This document failed to evidence measurable goals for pain, safety, symptom management and caregiver's coping ability. 6. Clinical record review on 6/22/2022 for patient #1, start of care 2/9/2022, and a primary diagnosis of Post COVID-19 condition and Adult failure to thrive evidenced an agency document titled "Hospice Plan of Care" for certification period 5/10/2022 - 8/7/2022, dated and electronically signed by RN H on 5/9/2022, and dated and signed by the attending physician on 4/12/2022. This plan of care had an area subtitled "Goals" which stated "Aide: Patient's personal care needs will be met ... Continuity of care will be maintained as appropriate to patient/primary caregiver needs ... family/caregivers will demonstrate the knowledge and ability required to provide safe and effective comfort care for dependent patient who is terminally ill ... family/caregivers will verbalize understanding of her pain/discomfort regimen ... patient/caregiver can verbalize realistic expectations in performance roll ...." This document failed to evidence measurable goals for safety, pain and caregiver expectations. 7. Clinical record review on 6/22/2022 for patient #11, start of care 9/30/2021, and a primary diagnosis of Malnutrition (the body does not get enough nutrients) evidenced an agency document titled "Hospice Plan of Care" for certification period 9/30/2021 - 12/28/2021, dated and electronically signed by the RN on 10/1/2021, and the attending physician on 10/2/2021. This plan of care had an area subtitled "Goals" which stated "Maintain clean, safe environment Patient's personal care needs will be met ... Patient/Caregiver will verbalize understanding of pain management regimen Family/caregiver will verbalize understanding of s/s [signs/symptoms] of impending death Provide patient/family with viable resources to meet the needs of the patient ...." This document failed to evidence measurable goals for safety, pain and verbalizing understanding of impending death. 8. Clinical record review on 6/16/2022, for patient #4, start of care 6/11/2022, evidenced an agency document titled "Hospice Plan of Care" for certification period 6/11/2022 - 9/8/2022. Review indicated the goals included, but were not limited to, patient/family will express satisfactory control of symptoms, patient/family will maintain necessary measures to reduce risk and avoid wound infection, and symptoms will be consistent with stage of disease process and problems managed as well as disease process will allow. Review failed to evidence the plan of care was individualized to include measurable goals specific to the patient. 9. Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, evidenced an agency document titled "Hospice Plan of Care" for certification period 3/24/2022 - 6/21/2022. Review indicated the goals included, but were not limited to, patient/family/caregiver will demonstrate a healthy, functional approach to dealing with patient situation and anticipated loss, promote skin integrity, and promote safe personal care and hygiene. Review failed to evidence the plan of care was individualized to include measurable goals specific to the patient. 10. Clinical record review on 6/17/2022, for patient #6, start of care 6/30/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 4/26/2022-6/24/2022. Review indicated the goals included, but were not limited to, patient's personal care needs will be met, provide patient/family with viable resources to meet needs of patient, patient/family will express satisfactory control of patient's symptoms, and patient/family wishes regarding end of life choices are honored throughout care. Review failed to evidence the plan of care was individualized to include measurable goals specific to the patient. 11. Clinical record review on 6/21/2022, for patient #12, start of care 6/21/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 6/21/2021-9/18/2021. Review indicated the goals included, but were not limited to, patient's personal care needs will be met and patient/family will express satisfactory control of patient's symptoms. Review failed to evidence the plan of care was individualized to include measurable goals specific to the patient. 12. Clinical record review on 6/21/2022, for patient #13, start of care 7/26/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 7/26/2021-10/23/2021. Review indicated the goals included, but were not limited to, patient/family will express satisfactory control of patient's symptoms, personal care needs will be met, maintain clean and safe environment, family will demonstrate ability to care for dependent patient, and patient/family verbalizes anxiety relief. Review failed to evidence the plan of care was individualized to include measurable goals specific to the patient. 13. During an interview on 6/22/2022, at 10:51 AM, RN C indicated the goals were standard and automatically pulled from the care plan. RN C indicated a measurable goal for skin integrity would be the patient would have no new wounds and no worsening wounds. 14. During an interview on 6/22/2022, at 2:12 PM, the patient family care coordinator indicated the goals were not measurable on the plan of care other than the pain goal. The patient family care coordinator indicated she now understood the goals should be measurable and patient specific. Based on record review and interview, the agency failed to ensure plans of care included measurable outcomes in 11 of 13 records reviewed (#1, 2, 3, 4, 5, 6, 7, 9, 11, 12, 13). The findings include: 1. Record review on 6/23/2022, evidenced an agency policy titled, "Plan of Care", revised 8/31/2021, which stated, " ... The plan of care will be developed by the IDG [interdisciplinary group] in accordance with the physician orders and the initial and comprehensive assessment of the patient which identify the care and services necessary to meet the needs of the patient / caregiver .... The patient's plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care includes, but is not limited to: a. Identification of problems. b. Measurable outcomes anticipated from implementing and coordinating the plan of care ...." 2. Clinical record review for patient #2 on 6/21/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Senile degeneration of brain, evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Goals:", which stated, "Aide: Patient's personal care needs will be met ... Patient / caregiver will demonstrate necessary behaviors to maintain good safety awareness ... Patient / family will express satisfactory control of symptoms ... Provide patient / family with viable resources to meet needs of patient ..." Review of the plan of care failed to evidence measurable goals for safety, control of symptoms, and resources to meet patient needs. 3. Clinical record review for patient #9 on 6/22/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Encephalopathy (any brain disease that alters brain function or structure), evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Goals:", which stated, "Chaplain: Patient and family will have spiritual needs met ... Patient's personal care needs will be met ... Promote safe personal care and hygiene ... Provide patient / family with viable resources to meet needs of patient ..." Review of the plan of care failed to evidence measurable goals for spiritual needs, personal care needs, and resources to meet patient needs.

Based on record review and interview, the agency failed to ensure the plan of care included all drugs and treatment necessary to meet the needs of the patient in 13 of 13 clinical records reviewed. (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13) The findings include: 1. Record review on 6/23/2022, evidenced an agency policy titled, "Plan of Care", revised 8/31/2021, which stated, " ... The plan of care will be developed by the IDG [interdisciplinary group] in accordance with the physician orders and the initial and comprehensive assessment of the patient which identify the care and services necessary to meet the needs of the patient / caregiver .... The patient's plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care includes, but is not limited to: a. Identification of problems. b. Measurable outcomes anticipated from implementing and coordinating the plan of care. c. A statement of the scope and frequency of services necessary to meet the specific patient and family needs. d. Interventions to manage pain and symptoms. e. Drugs and treatment necessary to meet the needs of the patient. F. Medical supplies and appliances necessary to meet the needs of the patient ...." 2. Clinical record review for patient #2 on 6/21/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Senile degeneration of brain, evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Medication:", which stated, "acetaminophen [a pain relieving and fever reducing medication] milligrams 325 - 1000 By Mouth; every 4 hours; PRN [as needed] for fever or pain ... lorazepam [an anti-anxiety medication] 2mg/ml [milligrams per milliliter]concentrate; Take 0.5 milligrams PO [by mouth]/SL [under the tongue] every one hour; PRN for anxiety, shortness of breath and nausea. Hospice SN [skilled nurse] may titrate ... morphine [a pain medication] 20 mg/ml concentrate; Take 2.5 milligrams PO/SL every 1 hour; PRN for pain and shortness of breath. Hospice SN may titrate ... senokot s [a laxative /stool softener] 1-2 By Mouth; daily as needed; May titrate. Max daily dose 8 tablets ...." Review of the plan of care failed to evidence instruction for dosing acetaminophen. Review of the plan of care failed to evidence instruction on titrating lorazepam, morphine, and senokot s. 3. Clinical record review for patient #8 on 6/22/2022, start of care 3/3/2022, certification period 6/1/2022 to 8/29/2022, primary diagnosis of Alzheimer's disease, evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Medication:", which stated, "acetaminophen [a pain relieving and fever reducing medication] milligrams 325 - 1000 By Mouth; every 4 hours; PRN [as needed] for fever or pain ... lorazepam [an anti-anxiety medication] 2mg/ml [milligrams per milliliter]concentrate; Take 0.5 milligrams PO [by mouth]/SL [under the tongue] every one hour; PRN for anxiety, shortness of breath and nausea. Hospice SN [skilled nurse] may titrate ... morphine [a pain medication] 20 mg/ml concentrate; Take 2.5 milligrams PO/SL every 1 hour; PRN for pain and shortness of breath. Hospice SN may titrate ... senokot s [a laxative /stool softener] 1-2 By Mouth; daily as needed; May titrate. Max daily dose 8 tablets ...." Review of the plan of care failed to evidence instruction for dosing acetaminophen. Review of the plan of care failed to evidence instruction on titrating lorazepam, morphine, and senokot s. Clinical record review evidenced an agency document titled, "Communication Notes". An entry by RN (registered nurse) D, dated 6/15/2022, stated " ... Has regular BM [bowel movement] pattern with miralax [a laxative] and prune juice ...." Review of the plan of care failed to evidence Miralax. 4. Clinical record review for patient #9 on 6/22/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Encephalopathy (any brain disease that alters brain function or structure), evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Medication:", which stated, " ... diazepam [an anti-anxiety and anti-seizure medication] milligrams 5 By Mouth; every hour; PRN for agitation / restlessness. Hospice SN [skilled nurse] may titrate ... haloperidol [an anti-psychotic] milligrams 0.5 By Mouth; every hour; PRN for agitation / restlessness. Hospice SN may titrate ... lorazepam [an anti-anxiety medication] 2mg/ml [milligrams per milliliter]concentrate; Take 0.5 milligrams PO [by mouth]/SL [under the tongue] every one hour; PRN for anxiety, shortness of breath and nausea. Hospice SN [skilled nurse] may titrate ... morphine [a pain medication] 20 mg/ml concentrate; Take 2.5 milligrams PO/SL every 1 hour; PRN for pain and shortness of breath. Hospice SN may titrate ...." Review of the plan of care failed to evidence instruction on titrating diazepam, haloperidol, lorazepam and morphine. 5. Clinical record review for patient #10 on 6/22/2022, start of care 5/11/2021, certification period 5/11/2021 to 8/8/2021, primary diagnosis of Heart failure evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Medication:", which stated, "acetaminophen milligrams 325 - 1000 By Mouth; every 4 hours; PRN [as needed] for fever or pain ... Albuterol [an inhaled medicine to help difficulty breathing] ... Inhale 2 puff(s) inhaled once a day as needed ... lorazepam Take 0.5 milligrams PO [by mouth]/ SL [under the tongue] every 1 hour; PRN [as needed] for anxiety, shortness of breath and nausea. Hospice SN may titrate ... morphine ... Take 2.5 milligrams PO / SL every 1 hour; PRN for pain and shortness of breath. Hospice SN may titrate ... senokot s tab(s) 1-2 By Mouth; daily as needed; May titrate ...." Review of the plan of care failed to evidence instruction on titrating lorazepam, morphine and senokot s. Review of the plan of care failed to evidence an indication for use of Albuterol and senokot s. 6. Clinical record review on 6/23/2022, for patient #3, start of care 11/05/2020, and a primary diagnosis of Alzheimer's Disease (a brain disorder affecting memory and thinking) evidenced an agency document titled "Hospice Plan of Care" for certification period 4/29/2022 - 6/27/2022, dated and electronically signed by employee B on 4/26/2022, and dated and signed by the attending physician on 5/10/2022. This plan of care had an area subtitled "Medication" which stated " acetaminophen milligrams 325 - 1000 By Mouth every 4 hours PRN for fever or pain; Do not exceed 4000 mg in 24 hours ... morphine milligrams 2.4 milligrams; every 1 hour PRN for pain and shortness of breath. Hospice SN may titrate ... lorazepam milligrams 0.5; every one hour; PRN for anxiety, shortness of breath. Hospice SN may titrate. The plan of care failed to include a patient-specific dosage of acetaminophen and failed to include orders on how the skilled nurse was to titrate the medication. 7. Clinical record review on 6/23/2022 for patient #7, start of care 3/31/2022, and a primary diagnosis of Cutaneous T-cell lymphoma (Cancer that begins in the white blood cells) evidenced an agency document titled "Hospice Plan of Care" for certification period 3/31/2022 - 6/28/2022, dated and electronically signed by employee F on 4/4/2022, and dated and signed by the attending physician on 4/5/2022. This plan of care had an area subtitled "Medication" which stated " acetaminophen milligrams 325 - 1000 By Mouth every 4 hours PRN for fever or pain; Do not exceed 4000 mg in 24 hours ... haloperidol milligrams 0.5 By Mouth; every hour; PRN for agitation/restlessness. Hospice nurse may titrate Concentration 2mg/ml ... lorazepam milligrams 0.5; every one hour; PRN for anxiety, shortness of breath. Hospice SN may titrate ... morphine milligrams 2.4 milligrams; every 1 hour PRN for pain and shortness of breath. Hospice SN may titrate ... Senokot S tab(s) [tablet(s)] 1-2 By Mouth daily as needed May titrate Max daily dose 8 tablets...." The plan of care failed to include a patient-specific dosage of acetaminophen and senokot and failed to include orders on how the skilled nurse was to titrate the medication. 8. Clinical record review on 6/22/2022 for patient #1, start of care 2/9/2022, and a primary diagnosis of Post COVID-19 condition and Adult failure to thrive evidenced an agency document titled "Hospice Plan of Care" for certification period 5/10/2022 - 8/7/2022, dated and electronically signed by RN H on 5/9/2022, and dated and signed by the attending physician on 4/12/2022. This plan of care had an area subtitled "Medication" which stated " ... lorazepam milligrams 0.5; every one hour; PRN for anxiety, shortness of breath. Hospice SN may titrate ... morphine milligrams 2.4 milligrams; every 1 hour PRN for pain and shortness of breath. Hospice SN may titrate ... oxygen liters per minute 2-4 via nasal cannula as needed May titrate up to 6 liters ... Senna-docusate sodium 8.6 /50 mg tablet orally 2 times a day as needed for relief/control of constipation; may titrate ...." The plan of care failed to include orders on how the skilled nurse was to titrate the medication. 9. Clinical record review on 6/22/2022 for patient #11, start of care 9/30/2021, and a primary diagnosis of Malnutrition (the body does not get enough nutrients) evidenced an agency document titled "Hospice Plan of Care" for certification period 9/30/2021 - 12/28/2021, dated and electronically signed by the RN on 10/1/2021, and the attending physician on 10/2/2021. This plan of care had an area subtitled "Medication" which stated " ... lorazepam 2 mg/ml concentrate take 0.5 milligrams PO/SL [by mouth/sublingual]; every one hour; PRN for anxiety, shortness of breath and nausea. Hospice SN may titrate ... morphine 20 mg/ml concentration. Take 2.5 mg PO/SL; every 1 hour PRN for pain and shortness of breath. Hospice SN may titrate ...." The plan of care failed to include orders on how the skilled nurse was to titrate the medication. 10. Clinical record review on 6/16/2022, for patient #4, start of care 6/11/2022, evidenced an agency document titled "Hospice Plan of Care" for certification period 6/11/2022 - 9/8/2022. Review indicated the patient's medications included, but were not limited to, acetaminophen 325 milligrams (mg) to 1000 mg and senokot 1-2 tabs daily as needed. Review failed to evidence the plan of care was individualized to include patient-specific dosage direction for medications ordered with a dosage range and failed to include the indications for use for when senokot was to be administered. Review indicated the patient's medications included, but were not limited to, lorazepam, morphine, and senokot and indicated the skilled nurse may titrate. Review failed to evidence the plan of care was individualized to include patient-specific direction for the titration of the lorazepam, morphine, and senokot. Review of an agency document titled "Medication Profile" dated 6/22/2022, indicated aspirin (a medication used to treat pain, fever, and/or prevention of stroke) 325 mg was discontinued on 6/17/2022. During an interview on 6/17/2022, at 11:33 AM, the patient's caregiver indicated aspirin 325 mg caused the patient nausea, vomiting, and stomach pain. The patient's caregiver indicated she has aspirin 81 mg to give the patient. During an interview on 6/17/2022, at 11:33 AM, RN D indicated giving the patient aspirin 81 mg daily was fine. Review failed to evidence the plan of care included aspirin 81 mg. During an interview on 6/22/2022, at 10:32 AM, RN C indicated the change in dose for the aspirin should have been included on the plan of care. 11. Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, evidenced an agency document titled "Hospice Plan of Care" for certification period 3/24/2022 - 6/21/2022. Review indicated the patient's medications included, but were not limited to, acetaminophen 325 mg to 1000 mg, atropine (medication used to dry up secretions) 1-4 drops every 2-4 hours, and senokot 1-2 tabs daily as needed. Review failed to evidence the plan of care was individualized to include patient-specific dosage direction for medications ordered with a dosage range and failed to include the indications for use for when senokot was to be administered. Review indicated the patient's medications included, but were not limited to, lorazepam, morphine, and senokot and indicated the skilled nurse may titrate. Review failed to evidence the plan of care was individualized to include patient-specific direction for the titration of the lorazepam, morphine, and senokot. Review of an agency document titled "Patient Changes Document" for the period 4/12/2022-4/26/2022, indicated the patient's medications included, but were not limited to, scopolamine (a medication used to treat nausea, vomiting, and/or to dry up secretions). Review failed to evidence the dose and route the scopolamine was to be administered. During an interview on 6/22/2022, at 11:26 AM, RN C indicated the route and dose was not included. 12. Clinical record review on 6/17/2022, for patient #6, start of care 6/30/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 4/26/2022-6/24/2022. Review indicated the patient's medications included, but were not limited to, acetaminophen 325 mg to 1000 mg and Senokot 1-2 tabs daily. Review failed to evidence the plan of care was individualized to include patient-specific dosage direction for acetaminophen and Senokot ordered with a dosage range. Review indicated the patient's medications included, but were not limited to, lorazepam, morphine, haldol (a medication used to treat certain types of mental disorders), and senokot and indicated the nurse may titrate. Review failed to evidence the plan of care was individualized to include patient-specific direction for the titration of the lorazepam, morphine, haldol, and senokot. 13. Clinical record review on 6/21/2022, for patient #12, start of care 6/21/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 6/21/2021-9/18/2021. Review indicated the patient's medications included, but were not limited to, acetaminophen 325 mg to 1000 mg. Review failed to evidence the plan of care was individualized to include patient-specific dosage direction for acetaminophen ordered with a dosage range. Review indicated the patient's medications included, but were not limited to, lorazepam and morphine and indicated the nurse may titrate. Review failed to evidence the plan of care was individualized to include patient-specific direction for the titration of the lorazepam and morphine. Review indicated bacitracin (an antibiotic ointment) was to be applied 1-2 times a week and as needed to skin tears and indicated bacitracin was to be applied daily as needed for skin tears. Review failed to evidence the plan of care was individualized to the specific needs of the patient for the frequency of the bacitracin. During an interview on 6/22/2022, at 11:44 AM, RN C indicated one bacitracin entry needed to be removed from the plan of care and indicated both orders could not be correct. 14. Clinical record review on 6/21/2022, for patient #13, start of care 7/26/2021, evidenced an agency document titled "Hospice Plan of Care" for certification period 7/26/2021-10/23/2021. Review indicated the patient's medications included, but were not limited to, acetaminophen 325 mg to 1000 mg, and senokot 1-2 tabs daily. Review failed to evidence the plan of care was individualized to include patient-specific dosage direction for acetaminophen and senokot ordered with a dosage range. Review indicated the patient's medications included, but were not limited to, lorazepam, morphine, and senokot and indicated the nurse may titrate. Review failed to evidence the plan of care was individualized to include patient-specific direction for the titration of the lorazepam, morphine, and senokot. 15. During an interview on 6/22/2022, at 10:16 AM, RN C indicated the plan of care should include specific orders for the titration of medications and indicated the medication should have a specific dose.

Based on record review and interview, the agency failed to include all durable medical equipment (DME) and medical supplies necessary to meet the patient's needs in the plan of care in 3 of 8 active records reviewed. (#5, 6, 7) The findings include: 1. The agency policy titled "Plan of Care" revised 8/31/2021, stated "... Policy: Hospice care and services provided to patients and their families are in accordance with an individualized, written plan of care established by members of the interdisciplinary group (IDG) in collaboration with the patient's attending physician (if any), the patient or representative and the primary caregiver. ... 2. The plan of care will be developed by the IDG in accordance with the physician's orders and the initial and comprehensive assessment of the patient which identify the care and services necessary to meet the needs of the patient/caregiver. ... 4. The patient's plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions. The plan of care includes, but is not limited to: ... . f. Medical supplies and appliances necessary to meet the needs of the patient...." 2. Clinical record review on 6/23/2022 for patient #7, start of care 3/31/2022, and a primary diagnosis of Cutaneous T-cell lymphoma (Cancer that beings in the white blood cells) evidenced an agency document titled "Hospice Plan of Care" for certification period 3/31/2022 - 6/28/2022, dated and electronically signed by employee F on 4/4/2022, and dated and signed by the attending physician on 4/5/2022. This plan of care had an area subtitled "Supplies" which stated "Overbed table, Adult diapers Urinal-Male; pressure release mattress; Bed Rails, Bed Pan; Hospital Bed; Other: BSC (bedside commode ...." This document failed to include all of patient #7's durable medical equipment. Clinical record review on 6/22/3022 for patient #7 evidenced an agency document titled "Skilled Visit Note" dated 5/10/2022. This document had a subsection titled "Narrative Note" which stated, " ... ambulates with a rollator with slow and deliberate steps. The rollator failed to be included on the patient's plan of care. Clinical record review on 6/22/2022 for patient #7 evidenced an agency document titled "Skilled Visit Note" dated 5/20/2022. This document had a subsection titled "Narrative Note" which stated, "... Pt was assisted in the shower today with shower chair and handheld shower device ...." The agency failed to include the shower chair on the patient's plan of care. Clinical record review on 6/22/2022 for patient #7 evidenced an agency document titled "Skilled Visit Note" dated 5/20/2022. This document had a subsection titled "Narrative Note" which stated, " ... Pt is up in wheelchair upon nurse arrival ...." The agency failed to include the wheelchair on the patient's plan of care. During an interview on 6/23/3022 at 2:11 PM, the clinical coordinator indicated any durable medical equipment the patient has should be listed on the plan of care. 3. Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, evidenced agency documents titled "Skilled Nursing Visit Note" completed by the registered nurse. Document dated 3/24/2022, indicated the patient had a condom catheter (a plastic tube connected to a collection device that fits over the penis like a condom that drains urine from the body). Document dated 3/25/2022, indicated the patient transfers with the use of a hoyer (a mechanical lift device). Review of an agency document titled "Hospice Plan of Care" for certification period 3/24/2022 - 6/21/2022, failed to evidence the plan of care included the condom catheter supplies and the hoyer lift. During an interview on 6/22/2022, at 11:03 AM, RN C indicated the plan of care should include the condom catheter supplies and the hoyer lift. 4. Clinical record review on 6/17/2022, for patient #6, start of care 6/30/2021, evidenced an agency document titled "Nurse Practitioner Visit Note" dated 5/28/2022. Review indicated the patient was sitting in a Broda chair (a medical positioning chair used to promote safety, pressure relief, and correct posture). Review evidenced an agency document titled "Hospice Plan of Care" for certification period 4/26/2022-6/24/2022, which failed to evidence the patient's medical equipment included a Broda chair. During an interview on 6/22/2022, at 10:47 AM, RN C indicated the Broda chair was not included in the plan of care and should be.

5. Clinical record review for patient #9 on 6/22/2022, start of care 6/14/2022, certification period 6/14/2022 to 9/11/2022, primary diagnosis of Encephalopathy (any brain disease that alters brain function or structure), evidenced an agency document titled, "Hospice Plan Of Care". The plan of care had a subsection titled, "Medication:", which stated, " ... diazepam [an anti-anxiety and anti-seizure medication] milligrams 5 By Mouth; every hour; PRN for agitation / restlessness. Hospice SN [skilled nurse] may titrate ... lorazepam [an anti-anxiety medication] 2mg/ml [milligrams per milliliter]concentrate; Take 0.5 milligrams PO [by mouth]/SL [under the tongue] every one hour; PRN for anxiety, shortness of breath and nausea. Hospice SN [skilled nurse] may titrate ... morphine [a pain medication] 20 mg/ml concentrate; Take 2.5 milligrams PO/SL every 1 hour; PRN for pain and shortness of breath. Hospice SN may titrate ...." Clinical record review evidenced an agency document titled, "HOSPICE OF THE CALUMET AREA, INC.-RILEY RESIDENCE DISPOSITION OF DRUGS". This document evidenced a sign-out sheet for Lorazepam, which evidenced a dose of 1 mg (milligram) of Lorazepam was given on 6/16/2022, and 1.5 mg was given on 6/20/2022. The document evidenced a sign-out sheet for Diazepam, which evidenced a dose of 10 mg of Diazepam was given on 6/17/2022. The document evidenced a sign-out sheet for Morphine, which evidenced a dose of 5 mg of Morphine was given on 6/16/2022, a dose of 10 mg was given on 6/18/2022, and a dose of 15 mg was given on 6/20/2022. Review of the plan of care and medication profile failed to evidence orders for the increased dosage of Lorazepam, Diazepam, and Morphine. During an interview on 6/20/2022, at 2:33 PM, RN B indicated a nurse may titrate a medication dose, they should write a new order and update the medication profile with the new dose so the next nurse knows what amount has been given. Based on record review and interview, the agency failed to ensure medications were given in accordance with the plan of care in 2 of 2 inpatient clinical records reviewed. (patient #9, #11) The findings include: 1. An agency policy titled "Medication Administration" revised 4/21/2020, stated, "... No change may be made to the medication dosage or route without a physician's order...." 2. An agency policy titled "Pain and Symptom Management" revised 12/15/2018, stated "The interdisciplinary group (IDG) will make every effort to effectively manage pain and control symptoms for Hospice of the Calumet Area (HCA) patients ... 5. Pain is reassessed during the completion of the hospice follow-up visit and hospice comprehensive assessment, every shift at the WJR residence, anytime of patient states that his/her pain level has changed, and whenever pain medication or dosage is changed. This information is documented in the patient's clinical record. The symptom assessment skills are also reassessed during completion of the hospice follow-up visit and hospice comprehensive assessment ... d. Each nurse will document medication administration on the Medical Profile and the Medication Administration Record ... When titrating medications, medication orders will be updated, which will update the Medication Profile and the Medication Administration Record ..." 3. An undated agency document titled "Written Guidelines for Symptom Control" received on 6/20/2022, stated "Titration Guidelines 1. Add total dosage of opioid given in 24 hours ... 2. Divide by dosing schedule ... If pain is particularly severe, the calculated dosage may be increased by an additional 20% to insure control ...." 4. Clinical record review on 6/22/2022 for patient #11, start of care 9/30/2021, and a primary diagnosis of Malnutrition (the body does not get enough nutrients) evidenced an agency document titled "Hospice Plan of Care" for certification period 9/30/2021 - 12/28/2021, dated and electronically signed by the RN on 10/1/2021, and the attending physician on 10/2/2021. This plan of care had an area subtitled "Medication" which stated "... morphine 20 mg/ml concentration. Take 2.5 mg PO/SL; every 1 hour PRN for pain and shortness of breath. Hospice SN may titrate ...." Clinical record review on 6/22/2022 for patient #11, evidenced an agency document titled "Hospice of the Calumet Area/William J Riley Residence Class II, III, IV, V Drugs Sign Out Sheet" which evidenced patient #11 was given 5 mg of Morphine on 9/30/21 at 5:25 PM, 5 mg of Morphine on 10/1/2021 at 3:50 PM, 5 mg of Morphine on 10/2/2021 at 10:15 PM, and 5 mg of Morphine at 1:50 AM. The agency failed to give the correct initial dose of 2.5 mg and subsequent doses of Morphine. During an interview on 6/20/2022 at 2:32 PM, the clinical coordinator indicated they have written guidelines for pain control. Nurses should start at the lowest dose and then increase the dosage or they can decrease the time between doses. She indicated a new order needs to be written for the increased dose, but the nurse can see what the last dose given to the patient was. During an interview on 6/22/2022 at 10:16 AM, the clinical coordinator indicated the medication order should be updated when a medication was titrated. She indicated nurses can give an increased dose for the first dosage if the nurse feels the ordered dose will not be effective.

Based on clinical record review and interview the agency failed to ensure assessments were complete to ensure they were meeting the needs of the patient in 1 of 2 inpatient hospice records reviewed. (patient #11) The findings include: An agency policy titled "Pain and Symptom Management" revised 12/15/2018, stated "The interdisciplinary group (IDG) will make every effort to effectively manage pain and control symptoms for Hospice of the Calumet Area (HCA) patients. 1. The nurse assesses the patient's pain and other symptoms as part of the initial assessment. Based on findings, the nurse ensures that the patient's care and support needs are met. All disciplines assess pain or distress as part of their comprehensive assessment and during follow-up visits. ... 5. Pain is reassessed during the completion of the hospice follow-up visit and hospice comprehensive assessment, every shift at the WJR residence, anytime of patient states that his/her pain level has changed, and whenever pain medication or dosage is changed. This information is documented in the patient's clinical record. The symptom assessment skills are also reassessed during completion of the hospice follow-up visit and hospice comprehensive assessment ...." Clinical record review on 6/22/2022 for patient #11, start of care 9/30/2021, and a primary diagnosis of Malnutrition (the body does not get enough nutrients) evidenced an agency document titled "Hospice Plan of Care" for certification period 9/30/2021 - 12/28/2021, dated and electronically signed by the RN on 10/1/2021, and the attending physician on 10/2/2021. This plan of care had an area subtitled "Medication" which stated "... lorazepam 2 mg/ml concentrate take 0.5 milligrams PO/SL [by mouth/sublingual]; every one hour; PRN for anxiety, shortness of breath and nausea. Hospice SN [skilled nurse] may titrate ... morphine 20 mg/ml concentration. Take 2.5 mg PO/SL; every 1 hour PRN for pain and shortness of breath. Hospice SN may titrate ...." Clinical record review on 6/22/2022 for patient #11, evidenced an agency document titled "Hospice of the Calumet Area/William J Riley Residence Class II, III, IV, V Drugs Sign Out Sheet" which evidenced patient #11 was given 5 mg of Morphine on 9/30/21 at 5:25 PM, 5 mg of Morphine on 10/1/2021 at 3:50 PM, 5 mg of Morphine on 10/2/2021 at 10:15 PM, and 5 mg of Morphine at 1:50 AM. Clinical record review on 6/22/2022 for patient #11, evidenced an agency document titled "Hospice of the Calumet Area/William J Riley Residence Class II, III, IV, V Drugs Sign Out Sheet" which evidenced patient #11 was given 0.5 mg of lorazepam doses on 9/30/21 at 5:25 PM, 10/1/2021 at 3:50 PM, 10/2/2021 at 10:15 PM, 10/3/2021 at 1:50 AM. Clinical record review on 6/22/2022 for patient #11, evidenced an agency document titled "MAR [medication administration record] History Report" this document indicated patient #11 received 5 mg of Morphine doses on 10/1/2021 at 4:10 AM, 10/1/2021 at 3:50 PM, 10/2/2021 at 12:24 AM, 10/2/2021 at 10:15 PM, and 10/3/2021 at 1:50 AM. This document failed to evidence the reason for administering the medication and failed to evidence patient #11 was reassessed for the effectiveness of the medication. Clinical record review on 6/22/2022 for patient #11, evidenced an agency document titled "MAR History Report" this document evidenced patient #11 received 0.5 mg lorazepam doses on 10/1/2021 at 4:10 AM, 10/1/2021 at 3:50 PM, 10/2/2021 at 12:24 AM, 10/2/2021 at 10:15 PM, and 10/3/2021 at 1:50 AM. This document failed to evidence the reason for administering the medication and failed to evidence patient #11 was reassessed for the effectiveness of the medication. Clinical record review on 6/22/2022 for patient #11 evidenced agency documents titled "Skilled Visit Notes" dated 9/20/2021, 10/1/2021, 10/2/2021, and 10/2/2021. These documents failed to evidence patient #11 was assessed for pain prior to medication administration, and failed to evidence the patient was reassessed for pain to ensure medication effectiveness. Clinical record review on 6/22/2022 for patient #11 evidenced agency documents titled "Shift Running Document" dated 9/20/2021, 10/1/2021, 10/2/2021, and 10/2/2021. These documents failed to evidence patient #11 was assessed for pain prior to medication administration, and failed to evidence the patient was reassessed for pain to ensure medication effectiveness. During an interview on 6/23/2022 at 1:23 PM, the clinical coordinator indicated there should be a documented assessment before and after pain medication was given.

Based on record review and interview, the hospice agency failed to ensure coordination of care with the skilled nursing facility to ensure medication/dosage/administration was current and correct, in 1 of 2 patient clinical records reviewed that resided in a healthcare facility. (#3) The findings include: 1. An agency policy titled "Nursing Facility Residents - Coordination of Care," revised 12/15/2018, stated "... Policy: HCA [Hospice of the Calumet Area] ensures that mechanisms are in place to provide for coordination of all hospice services provided to patients residing in facilities. Procedure: 1. HCA designates the RN [registered nurse] case manager as the member of the interdisciplinary group (IDG) that is responsible for a patient who is a resident of a facility. The designated IDG member is responsible for: a. providing overall coordination of the hospice care of the resident with facility representatives; b. communicating with facility representatives and other health care providers participating in the provision of care for the terminal illness and related conditions and other conditions to ensure quality of care for the patient and family. As part of the patient visit, hospice staff will meet with a facility representative to obtain an update on the patient's condition, provide education on end of life care as needed and review the plan of care ... 3. The following information is provided to the facility: a. the most recent hospice plan of care specific to each patient ... f. hospice medication information specific to each patient ...." Clinical record review on 6/23/2022, for patient #3, start of care 11/05/2020, and a primary diagnosis of Alzheimer's Disease (a brain disorder affecting memory and thinking) evidenced an agency document titled "Hospice Plan of Care" for certification period 4/29/2022 - 6/27/2022, dated and electronically signed by employee B on 4/26/2022, and dated and signed by the attending physician on 5/10/2022. This plan of care had an area subtitled "Nutrition" which stated "Mechanical Soft." This plan of care also had an area subtitled "Medication" which stated "acetaminophen milligrams 325 - 1000 By Mouth every 4 hours PRN [as needed] for fever or pain; Do not exceed 4000mg in 24 hours ... Aspercreme with Lidocaine 4% topical cream apply 1 application topical 2 times a day for pain. Apply thin layer to right upper back ... morphine milligrams 2.4 milligrams; every 1 hour PRN for pain and shortness of breath. Hospice SN [skilled nurse] may titrate ... Nystatin topical 100000 units/g [gram] topical powder take one application applied 3 rimes day as needed; apply under breast folds 3X/day after cleaning area with mild soap and water and patting dry...." Clinical record review on 6/23/2022, of a document titled "Physician Order Report" from facility A evidenced an area subtitled "Medication Flow Sheet" which stated, "Diet: Mechanical soft, PUREE MEAT ... Morphine 20 mg/mL (4mg/mL) give 0.25 mL oral every hour PRN ... acetaminophen capsule 325 mg 2 tablets oral every 4 hours PRN ...." Clinical record review on 6/23/2022, failed to evidence the hospice agency coordinated care with facility A regarding the correct dosage of morphine, acetaminophen, Aspercreme, and Nystatin, and failed to ensure they had the correct diet for patient #3. During an interview on 6/24/2022 at 3:06 PM, employee B indicated the plan of care and the medications listed on agency A's documents should be the same as what was on the agency's plan of care.

Based on observation, record review, and interview, the agency failed to follow standard precautions in 1 of 2 home visits with the registered nurse (RN). (#4) The findings include: Review of an agency policy obtained on 6/22/2022, titled "Standard Precautions" revised 8/27/2019, stated, "... Change gloves between tasks and procedures on the patient if the hands will move from a contaminated body-site ... to a clean body-site ... Remove gloves promptly after use, before touching uncontaminated items and environmental surfaces ... Always perform hand hygiene after removing gloves...." During an observation of care at the home of patient #4, start of care 6/11/2022, on 6/17/2022, at 10:59 AM, RN D was observed wearing gloves while cleaning multiple open areas on the right lower leg by spraying liquid on a clean gauze pad from a bottle labeled "Wound Cleanser". RN D was not observed removing gloves and performing hand hygiene after cleaning one wound and before cleansing another wound. RN D was observed rinsing multiple wounds on the right lower leg with a solution in a syringe titled "normal saline [a liquid solution]" and drying with a clean dry gauze. RN D was not observed removing gloves and performing hand hygiene after rinsing and drying one wound and before rinsing and drying another wound on the right leg. RN D was observed applying an ointment from a tube labeled "triple antibiotic ointment" to a clean gauze pad and applied the ointment to the open areas on the right lower leg. RN D was observed applying a bandaid to one open area to the right lower leg. RN D was observed cleaning multiple open areas to the left lower leg with the wound cleanser. RN D was not observed removing gloves and performing hand hygiene after applying ointment and a bandaid to the open area on the right lower leg and before cleansing the wounds on the left lower leg and was not observed removing gloves and performing hand hygiene after cleansing one wound on the left lower leg and before cleansing another wound on the left lower leg. RN D was observed rinsing the wound on the left lower leg with normal saline and a patting dry with a dry gauze. RN D was not observed removing gloves and performing hand hygiene after rinsing and drying one wound on the left lower leg and before rinsing and drying another wound on the left lower leg. RN D was observed applying ointment to a clean gauze and applying ointment and covering with a bandaid to open areas on the left lower leg. RN D was not observed removing gloves and performing hand hygiene after applying ointment and a bandaid to one wound and before applying ointment and a bandaid to another wound on the left lower leg. During an interview on 6/17/2022, at 4:59 PM, the patient family care coordinator indicated gloves should be removed and hand sanitizer should be applied after cleaning wounds and before applying wound dressing. The patient and family care coordinator indicated gloves should be changed and hand sanitizer should be applied in between wound care to different wounds.

Based on record review and interview, the agency failed to maintain a program for the surveillance, identification, and investigation of infectious diseases. The findings include: Review of an agency policy obtained 6/22/2022, titled "Infection Control Program" revised 1/1/2014, stated, "... HCA's [Hospice of the Calumet Area] infection control program includes, but is not limited to the following components: ...collection and analysis of surveillance data related to infections among Partners, volunteers and hospice patients ...." Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, evidenced an agency document titled "Skilled Nursing Visit Note" completed by the registered nurse and dated 3/28/2022. This document indicated the patient's urine had an odor and the patient had a history of urinary tract infections. Review indicated the patient was to start Bactrim (an antibiotic). Review of the agency's infection log failed to evidence an infection investigation was completed for the patient. During an interview on 6/22/2022, at 11:29 AM, registered nurse (RN) C indicated the nurse should have documented the patient's infection under the infection tab on the flowsheet and indicated the infection report was not generated because the nurse did not document the infection correctly.

Based on record review and interview, the agency failed to ensure nursing services followed the hospice's policies and procedures in 1 of 2 discharged records reviewed receiving wound care (#10). The findings include: Record review on 6/23/2022 evidenced an agency policy titled, "SKIN CARE PROTOCOL", dated 4/16/2009, which stated, " .... For any areas of skin breakdown, note location, stage (if pressure ulcer), size (length, width, depth), tissue type (granulating or eschar), tenderness / pain, drainage, odor and condition of surrounding skin (redness, maceration [softening and breaking down of the skin]) ...." Clinical record review of the electronic medical record (MatrixCare) for patient #10 on 6/22/2022, start of care 5/11/2021, certification period 5/11/2021 to 8/8/2021, primary diagnosis of Heart failure, evidenced a wound flowsheet. The wound flowsheet evidenced entries dated 5/21/2021, 5/24/2021, 5/27/2021 and 6/3/2021. Each of the entries failed to evidence wound measurements. Clinical record review failed to evidence any wound measurements. During an interview on 6/23/2022 at 1:32 PM, RN [registered nurse] C indicated the nurse should measure wounds once a week, usually on the first visit on the week. When informed of the findings, RN C and RN B reviewed the clinical record, and indicated it failed to evidence any wound measurements.

Based on record review and interview, the agency failed to provide physical and occupational therapy services in 1 of 2 home visits conducted with the registered nurse. (#4) The findings include: Review of an agency policy obtained 6/22/2022, titled "Physical, Occupational, Speech and Other Therapies" dated 12/2/2008, stated, "... Physical therapy services, occupational therapy services ... are provided when necessary for the management of symptoms ... During the comprehensive assessment of the patient, the need for physical, occupational ... services is evaluated. When these services are needed to help the patient reach optimal functioning, a physician's order is obtained and the services to be provided are included in the patient's plan of care...." Clinical record review on 6/16/2022, for patient #4, start of care 6/11/2022, evidenced an agency document titled "Skilled Nursing Visit Note" completed by the registered nurse (RN) and dated 6/11/2022. Review indicated the patient required occasional assistance and/or rest periods with ambulation and swayed but was able to catch himself. Review indicated the patient was deconditioned and weak. Review failed to evidence the patient was offered physical and occupational therapy. During an interview on 6/17/2022, at 10:30 AM, the patient indicated he ambulates outside using a cane. Patient indicated he wants to improve so he can return to the city and walk around to shop and visit his friends. During an interview on 6/21/2022, at 1:35 PM, the patient's caregiver indicated she was unaware the agency provided physical and occupational therapy and indicted she thought therapy would be good for the patient so he could keep his strength for as long as possible. During an interview on 6/22/2022, at 2:03 PM, the family patient care coordinator indicated therapy would be provided if therapy would improve the patient's quality of life and help the patient do the things the patient likes to do. The family patient care coordinator indicated the patient could benefit from having therapy services and indicated the RN had not followed up on it yet.

Based on observation, record review and interview, the hospice aide failed to provide all services ordered in the patient's plan of care in 1 of 1 hospice aide visit. (patient #3) The findings include: An agency policy titled "Hospice Aide Assignments and Duties" revised 4/21/2020, stated "Hospice Aides (HA) are expected to complete all assignments under the supervision of an RN [Registered Nurse] ... HAs are expected to complete all scheduled assignments ... 3. A hospice aide provides services that are a. Ordered by the interdisciplinary group. b. included in the plan of care. c. Permitted to be performed under State law by such hospice aide. d. Consistent with the hospice aide training and competency ...." Clinical record review on 6/23/2022, for patient #3, start of care 11/05/2020, and a primary diagnosis of Alzheimer's Disease (a brain disorder affecting memory and thinking) evidenced an agency document titled "Aide Care Plan" with a subsection titled Interventions," which stated "Hygiene-Shampoo" Clinical record review on 6/23/2022, for patient #3, evidenced an agency document titled "Aide Visit Note" dated 6/17/2022, and signed by Hospice Aide E, with a subsection titled "Care Plan Documentation" which stated "Hygiene-Shampoo-Done." During a home visit on 6/17/2022, at 9:35 AM, Hospice Aide E was observed providing care to patient #3. Hospice Aide E was observed giving a bed bath to patient #3. Hospice Aide E failed to shampoo patient #3's hair during this visit. During an interview on 6/20/2022 at 12:17 PM, the clinical coordinator indicated if the patient has no order to shampoo her hair as part of the aide care plan, the aide should have completed the task or documented why it was not completed.

Based on record review and interview, the agency failed to ensure the clinical record included clinical notes for 1 of 9 active clinical records reviewed. (#5) The findings include: Review of an agency policy obtained on 6/22/2022, titled "Documentation Requirements" revised 9/4/2019, stated, "... All visit documentation should be closed within 24 hours of the visit...." Clinical record review on 6/21/2022, for patient #5, start of care 3/24/2022, failed to evidence documentation of skilled nursing visits provided to the patient since 5/17/2022 except for a visit on 6/7/2022. During an interview on 6/22/2022, at 11:31 AM, registered nurse (RN) C indicated visit notes should be completed within 24 hours per agency policy and was unsure why the nurse visits were not documented since 5/17/2022. When queried if there were any additional skilled nursing visits completed that were not yet included in the clinical record, RN C indicated she would check. During an interview on 6/22/2022, at 2:30 PM, the patient family care coordinator indicated RN D was behind in completing his documentation and it was unacceptable. Review of a untitled agency document provided on 6/22/2022, at 3:00 PM, indicated RN D provided skilled nurse visits to the patient on 6/3/2022, 6/10/2022, 6/14/2022, 6/17/2022, and 6/22/2022 and indicated RN D was working on completing the documentation.

Based on observation, record review and interview, the agency failed to ensure the clinical record was safeguarded against unauthorized use. The findings include: Review of an agency policy obtained on 6/22/2022, titled "Clinical Records, HCA [Hospice of the Calumet Area] Hospice Patients" revised 4/21/2020, stated, "... Access to patient clinical records is restricted to members of the IDG [interdisciplinary group] and Partners or volunteers who require such access to perform their jobs effectively...." During an observation at the branch location on 6/17/2022, at 9:12 AM, cardboard boxes labeled "To Be Shredded" were observed in an unlocked, open room. Inside of the cardboard boxes were agency documents with clinical information to include patient names. During an interview on 6/17/2022, at 2:08 PM, the administrator indicated clinical documents were to be shredded after they were scanned into the electronic health record. During an interview on 6/22/2022, at 10:44 AM, the administrator indicated the documents located in the cardboard boxes in the open room at the branch location used to be stored in a locked office but the water heater burst and the documents had to be moved temporarily.

Based on record review and interview, the agency failed to provide to the patient's physician a copy of the discharge summary per the agency's policy in 1 of 3 closed records reviewed with a patient death. (#13) The findings include: Review of an agency policy obtained 6/22/2022, titled "Death of a Patient" revised 5/1/2015, stated, "... The patient's death is pronounced, documented on ... the Agency Discharge Summary and communicated in accordance with State laws and regulations...." Review on 6/20/2022, of an untitled agency document indicated patient #13, start of care 7/26/2021, expired on 7/8/2021. Clinical record review on 6/21/2022, for patient #13 failed to evidence a discharge summary. During an interview on 6/22/2022, at 11:57 AM, registered nurse (RN) C indicated the discharge summary should have been completed and sent to the physician. At 4:22 PM, RN C indicated there was not a discharge summary in the clinical record.